Academic Detailing in 2016: Challenges & Opportunities

1. Academic Detailing in 2016:Challenges & Opportunities DHCS Academic Detailing Conference Sacramento, California | October 2016 Michael A. Fischer, M.D., M.S. Director, National Resource Center for Academic Detailing Division of Pharmacoepidemiology and Pharmacoeconomics Brigham and Women’s Hospital | Harvard Medical School

2. Sources of Support • NaRCAD is supported by a grant from the Agency for Healthcare Research and Quality (AHRQ) • My current research projects are funded by AHRQ, FDA, PCORI, NIH, CVS-Caremark and Surescripts. • I consult for Alosa Health, a non-profit that supports academic detailing programs. I do not accept personal compensation of any kind from any pharmaceutical companies, health insurers or device manufacturers. • DoPE accepts occasional unrestricted research grants from drug companies or health insurance companies to study specific drug safety and utilization questions.

3. The Lay of the Land • Medical care should be effective, safe, and as affordable as possible. • But: • We know that medical care is not optimal • Effective therapies underused • Adverse events and errors common • Patients struggle to pay medical bills • and programs have trouble with rising expenses…

4. EBM in the Modern Era • Increasingly effective treatments • Better understanding of risks/harms • Mandate for health care system: Identify effective and safe treatments Increase their use Avoid causing harm

5. Gaps in Care • 2013 stats: • 25 percent don’t get recommended cancer screenings • 49 percent get inappropriate cancer screenings • 56 percent have inappropriate antibiotic use • 32 percent do not get recommended diabetes care -Levine et al. JAMA Intern Med, 2016.

6. Academic Detailing to Close the Gaps Best Available Evidence Actual Clinical Practice

7. …So that clinical decisions are based on the most current and accurate evidence about: • Efficacy • Safety • Cost-Effectiveness

8. The Logic of Academic Detailing • Medical, pharmacy and nursing school faculty have a solid grasp of the evidence about treatment benefits and risks… • but are not always expert communicators. • Industry reps are superb communicators… • but their primary goal is to increase sales. • Can the contentof the former be communicated to prescribers through a ‘delivery system’based on the latter?

9. Origins of Academic Detailing • 1970s: effectiveness of marketing approach of pharmaceutical detailers • Limitations of existing methods of continuing education for clinicians • Initial randomized trials to test providing academically valid content with the techniques of social marketing

10. The First AD Research • New health policy interventions need to be tested rigorously, just as new drugs are • Four-state randomized controlled trial, published in New England Journal of Medicine • Avorn & Soumerai, NEJM, 1983 • The reverse side of each “un-ad” contained concise clinical background and specific prescribing recommendations • with references

14. Further AD Studies • AD in long term care • Cluster-randomized RCT of nursing homes • 11-25 percent reductions in use of sedating meds • Avorn et al., NEJM, 1992 • AD in inpatient setting • RCT targeting med/surg transfusion practice • 40 percent relative reduction in inappropriate transfusion • Soumerai et al., JAMA, 1993

17. Lessons from Initial Studies • Proof of concept • Effective in multiple settings Emerging Insights • “Just say no” not enough • Physicians need support for patients • Involvement of non-physician providers

18. Academic Detailing Evidence Base • Evaluated extensively in multiple settings • 2007 Cochrane review • Combined 69 studies • Median adjusted improvement: 21 percent (IQR 11-41 percent) • In direct comparisons, EOV slightly more effective than audit and feedback • Updated Cochrane review in preparation -O’Brien MA, Rogers S, et al. Cochrane, Database of Systematic Reviews 2007

19. From Research to Practice • AD programs established in 1980s – 1990s • Australia, some European countries • Kaiser Permanente in California • Limited initial uptake • Funding models challenging • Growth in this century • Additional large organizations (For example, VA) • More proactive focus on quality improvement • Increased responsibility for outcomes

20. Evolution of Academic Detailing

21. Created with a grant from AHRQ in 2010, renewed 2014-2018

22. Building Successful AD Programs • Context is critical; each site has different challenges • Building capacity in organizations creates sustained opportunities • NaRCAD strengthens partner programming with timely, customized, longitudinal, support and collaboration

23. AD in Multifactorial Interventions • Intervention targets will vary for different clinical problems • AD can play a key role when interventions require: • Clinician engagement • Education on best evidence • Behavior change • AD can complement other elements of an intervention: • Practice facilitation • Health IT • Financial incentives

24. NaRCAD Support: AHRQ EvidenceNow

25. NaRCAD Support & Collaboration:San Francisco Dept. of Public Health • PrEP prescribing in priority populations: • Program Development and Customized Training • Naloxone co-prescribing: • Program Support & Materials Development

26. NaRCAD & Mass. Department of Mental Health Ongoing Collaboration, Materials Development, Support, Interview in our Best Practices Blog, and Special Presentation at NaRCAD2016

27. NYC Department of Health & Mental Hygiene Interview in our Best Practices Blog on Scaling Up and Modeling Best Practices for Program Development and Team Preparation

28. Other Trends: Clinical Topics our Partners are Working on

29. Current Challenges

30. Conflict in Guidelines • What age for mammograms? • What targets for hypertension? • Should we use LDL to guide cholesterol treatment?

31. The Volume of “Evidence” is Overwhelming Not all evidence is of equal quality • In 1992, internists needed to read an estimated 17 articles every day of the year in order to “keep up” with the literature • The volume of published articles since then has increased exponentially • Made more difficult because not all evidence is of equal quality (i.e. difficult to identify those studies that are particularly important) • Creates a virtually impossible problem for practicing physicians SOURCES: Davidoff et al BMJ 1995; 310: 1085; http://www.nlm.nih.gov/bsd/medline_lang_distr.html

32. AD to Deal with Evidence Overload • Sorting out signal from noise • Importance of honest brokers who can interpret that data and provide practical advice • Needs to be usable for front-line clinicians

33. Economic Pressures Increasingly, clinicians struggle with: Prior authorization requirements Formularies Algorithms Marketing

34. Economic Pressures • Addresses the need for a trustworthy source to identify which innovations are worth adopting • AD is not just “counter-detailing” (e.g. HIV PrEP)

35. Primary Care Burnout: Stats 55 percentof primary care physicians in a 2015 Survey identified as “burned out” 10 percentof these physicians identified their burnout as “so severe I’m thinking of leaving medicine.” MedScape 2015

36. What Clinicians Value: Academic Detailing offers: • Engagement • Sense of Purpose • Ability to Reinvigorate Primary Care Respect Professionalism Mastery

37. Dedicated National and Global Network of Partners • Specialized Techniques Training Courses • International Conference on Academic Detailing • Virtual Resources, Tools, and Best Practices Sharing

38. Our Partner Network

43. Stories from the Field

44. Media Highlights

45. Moving Forward Together • Dedication to the Field: NaRCAD’s expert, customized consultation strengthens the impact of clinical outreach education programming in the United States and beyond. • Expert Consultation: Our team is well-versed in the current landscape of health care, the unique challenges facing primary care, and creating successful clinician behavior change. • Ever-Increasing Impact & Network: The success of our community, resources, trainings and conferences grows with each year, as we connect experts in the field and highlight their work. We’re looking forward to new partnerships and successes in 2017!

46. Division of Pharmacoepidemiology and PharmacoeconomicsBrigham and Women’s Hospital and Harvard Medical School419 Boylston Street, Floor 6 | Boston, MA 02116857.307.3801 | narcad@partners.org www.narcad.org Connect with us on social media: